Health Survey

All information is confidential and private.

If there was one thing you could change about your health today, what would it be?

Please Select any box that may apply to you, your family, or friends.

Sleep Quality

You

Family/Friends

Weight Loss

You

Family/Friends

Joint & Ligament Flexibility

You

Family/Friends

Heart Health

You

Family/Friends

Respiratory Health

You

Family/Friends

Digestive Health

You

Family/Friends

Improved Sense of Well-Being

You

Family/Friends

Joint Support

You

Family/Friends

Foot & Muscle Maintenance

You

Family/Friends

Healthy Immune Function

You

Family/Friends

Skin Health

You

Family/Friends

Energy and/or Healthy Alternatives to Energy Drinks

You

Family/Friends

Other Health Concerns:

Do you take vitamins or herbals of any kind?

Are you under the supervision of a health professional?

Do you take prescription medication?

Is there any reason why you would not be willing to use a product related to these concerns?

Name:

Age:

Address:

Phone:

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